Digital preoperative assessment (POA) at Guy’s and St Thomas’ NHS Foundation Trust (GSTT)

GSTT preoperatively assesses:

• 20,000 to 25,000 patients a year for elective surgery
• 19,000 patients a year for endoscopy procedures

This includes anyone coming for procedures requiring general anaesthetic through a centralised POA clinic. This encompasses the pathway from ‘decision to treat’ through to the patient being booked on and having their operation.

Situation

COVID-19 meant the GSTT preoperative assessment service had to rapidly change its processes.

Previously, all patients had a 1 hour face-to-face appointment.

COVID-19 led to all preoperative assessments being completed on one-to-one telephone calls and nurses recording verbal assessments on paper. This brought about a number of challenges in that:

• with no training, nurses had to adapt to telephone consultations
• patients wanted to chat (due to the nature of isolation as a result of COVID-19) and this made completing paper forms over the telephone time consuming and inefficient

Aspiration

The Trust wanted to improve patient experience. This included:

• patients completing questionnaires from home to minimise visits to hospital
• giving patients ownership over their care
• improving data collection
• improving the ability to identify high-risk patients and manage accordingly
• increasing oversight of patients for surgical specialties
• reducing the time nurses spend assessing patients with a physical status classification of 1 or 2 from the American Society of Anaesthesiologists (ASA) to increase capacity and save money

Solution

In August 2020, a digital solution was implemented to support patients and staff in the POA pathway.

Ultramed MyPreOp is a complete POA solution. It includes completed patient questionnaires, a portal for clinicians to manage pathways, and the ability to generate and review operational reports.

MyPreOp facilitates efficient theatre booking with visibility of where each patient is in the POA process.

Impact

• Patients can enter their information, empowering them in their care.
• Journeys to hospital for POA have reduced, cutting down carbon emissions.
• Nurses need to collect less data and so save time.
• There is support for clinical decisions and risk management.
• A centralised POA system better facilitates theatre bookings across healthcare providers.

The Trust measured the initial impact of digital pre-assessment across 3 key areas:

• clinical outcomes
• efficiency
• patient satisfaction

When it comes to clinical outcomes, the team identify high-risk patients early who can be optimised before surgery. This improves patient health outcomes during and after surgery.

ASA1 and simple ASA2 patients (20% of the patient cohort) no longer need a full 1 hour face-to-face appointment with a nurse. Instead, nurses spend 20 minutes reviewing notes which includes a short phone call. This saves time, frees up clinic capacity and reduces patients’ visits to hospital.

Over 1,500 patients were surveyed. Approximately 97% said that their experience of using MyPreOp was very good, good or neutral.

3,741 patients had a POA in March to May 2021. 96% of all patients were able to complete their digital questionnaire. 4% of patients were unable to complete their digital questionnaire. They were booked in for a telephone slot with a registered nurse who completed it on their behalf.

Functionality

Once it’s determined a patient needs surgery, they receive a unique code and completion instructions for MyPreOp. They then complete an online questionnaire which includes medication and medical history.

The questionnaire takes 30 to 60 minutes to complete and patients can finish it in several sittings.

The patient owns their data. It’s stored within Ultramed’s cloud-based system.

After the patient completes the questionnaire, the system:

• generates an ASA grade
• suggests follow-up tests and actions
• summarises key information for the POA team

Clinicians input their clinical notes together with the information entered by the patient to generate a POA report. This summarises key information and action for the anaesthetist on the day.

The system is user-friendly for patients. It has several functions that support the work of different teams. For example:

• administrative staff can manage and track patients using the service dashboards
• POA nurses and anaesthetists can view patients assigned to them

There are several system features that enable efficiency.

• Surgical specialties dashboards only show the clinician’s patients.
• Pre-assessment nurses can transfer patients between services.
• Patients can be assessed by 1 healthcare provider and transferred to another before surgery. This facilitates integrated care systems and the use of surgical hubs.

Capabilities

• Clinicians can prioritise clinically urgent patients or those with 'to come in' dates using dashboard filters.
• Patients can be assigned to specific clinicians.
• Specialties register their patients on MyPreOp as opposed to patients self-registering.
• Patients receive invites by email or SMS with automatic reminders.
• Surgical specialties have oversight of where their patients are in the pre-assessment pathway.
• Automated weekly reports and live service specific dashboards provide key metrics for management.
• Patients who complete a preoperative online questionnaire can complete postoperative questionnaires.
• Surgical notes are not included specifically and are instead held in the electronic health record.

Scope

Patients and clinicians can use MyPreOp at home or in the hospital on any device connected to the internet.

It allows anaesthetists to view completed POAs for patients who are on their operating lists days in advance.

MyPreOp can be easily scaled up and has been implemented remotely in 7 Trusts since the start of COVID-19.

Key learning points

• A significant amount of change management is needed to transform the POA pathway.
• Implementation was supported with 0.7 whole time equivalent project management.
• Early engagement, education and implementation support for various teams is vital for a smooth rollout, especially when communicating with patients about the process.
• Creating video guides, handbooks, action cards and superusers helped to train over 100 staff to use MyPreOp.
• Some patients will be unable to use MyPreOp. Ensuring they have a questionnaire completed on their behalf is a time-consuming process for nurses.
• Engaging with patients from the outset is key to ensuring they understand the need for MyPreOp and the importance of completing it on time.
• GSTT worked alongside Ultramed to develop features that aligned with internal workflows to create efficient processes.
• GSTT reached out to other Trusts using the system to share learnings and best practices.
• Reports were generated by Ultramed and shared in weekly performance meetings. This facilitated operational analysis and conversations within management teams about improvements to processes.

Key quotes

"Extensive pathway mapping is essential in ensuring the smooth rollout for MyPreOp. This involves mapping admin and clinical pathways from beginning to end and solidifying learning through training sessions. All working groups must be fully engaged as early as possible in order to adapt the new processes.

Trial and error is important and teething issues are to be expected!"

Camilla Dobinson, Service Manager, Theatres and POAC

Find out more

Case study on the potential impacts of a digital POA service on appointments, travel-related carbon dioxide emissions, and user experience

Case study on monitoring the continuous user experience of a patient-completed POA system

MyPreOp case study on the NHS Innovation Accelerator website

MyPreOp rapid overview for clinicians demo video

Key contact

Camilla Dobinson, services manager, Main Theatre and PreOp, GSTT

camilla.dobinson@nhs.net

Dr Paul Upton, Co-founder and CEO, Ultramed Ltd

info@ultramed.co